Trail Making Test: Normative data for Turkish elderly population by age, sex and education☆
Introduction
Trail Making Test (TMT) was first developed in 1944 as a visual–motor and visual–conceptual trail making test, as a part of ‘Army Individual Test Battery’, which was prepared by psychologists in the United States Army and released for public use in the following years [1]. The first version of TMT was composed of two separate parts, as A and B. In the first part (Part A), the participant is required to combine the numerated circles with direct lines to provide correct alignment of numbers in an ascending order (as 1-2-3-4-…). In the second part (Part B), the participant is required to combine the circles, which are consisted of both letters and numbers with direct lines to provide correct alignment of both numbers and letters in an ascending order, as one number and one letter (1-A-2-B-3-C-…).
Test procedure and scoring was subjected to a number of modifications in time during its development. In its original version, the test was completed by the tester after three corrected mistakes. Every trial was assessed on a 10 point scale and the length of time to complete the test comprised the primary data for the assessment. Armigate et al. modified this assessment method without considering the number of mistakes they had made and permitted the participants to continue the test even though three mistakes or more were recorded [2]. Corrected mistakes were recorded as zero points. Similarly, Reitan et al. ignored the number of mistakes and measured the time period for test completion [3]. In the following years, Spreen and Staruss prepared detailed instructive measures for test practice and restricted the time period (4 to 5 min) necessary to complete the test [4]. Currently, simplified TMT scoring method is still being used in the form proposed by Reitan et al., despite some critics [3]. Some authors criticized these instructive measures, which seemed to threaten the test reliability, depending on the fact that it could result in some mistakes due to reaction time of the tester, if the duration of test is regarded. Moreover, additional mistakes could be made if a participant tries to be faster and more time is spent for correcting the mistakes. This method indirectly punishes the mistakes, however does not control the duration of time spent for mistakes and/or corrections. As a summary, there is a potential bias on the time scoring method due to individual differences [5], [6].
The difference obtained by subtraction of Part A score from Part B score (Score B − A) is used to eliminate speed component, which is a variable in evaluation of TMT. This difference is shown to be highly correlated with both mental ability tests and various cognitive disturbances [7]. The TMT test was further developed into different forms, like Oral Trail Making Test [8] and Comprehensive Trail Making Test [9], which were adapted to various cultures and/or languages [10], [11].
TMT is one of the most widely used screening tests in clinical neuropsychology practice [4], [6], [9]. From neuropsychological point of view, frontal lobes are brain regions responsible from the higher levels of cognitive functions [6]. Working memory, complex attention, planning, cognitive set shifting, response inhibition, problem solving and other executive functions may well be taken into account when the role of frontal lobe is considered. TMT, particularly Part B, is a widely used neuropsychological scale for executive functions like complex attention, planning, cognitive set shifting and response inhibition [6], [12]. Participants with frontal lobe damage were shown to have low Part B scores, while no difference was detected among the Part A scores of patients with or without any frontal lobe damage [12], [13]. Nevertheless, there are other clinical studies featuring patients with frontal lobe damage with low performance scores both in Parts A and B in comparison to normal participants [14], [15].
In a particular study concerning patients with mild, moderate and severe dementia, patients were compared in terms of Part A, Part B and total time scores of Parts A and B (Score A + B). When the dementia increases in severity, mean time spent to complete each part increased and the difference between groups was found to be statistically significant [16]. Besides, association between TMT time scores and Wechsler Adult Intelligence Scores (WAIS) was investigated, and TMT time scores of Parts A and B were found to be inversely correlated with WAIS scores (verbal and performance subtest scores, together with total IQ scores) [16], [17].
Section snippets
Features of Trail Making Test
TMT is a complex visual screening test that has motor components and it is sensitive to frontal lobe functions [12], [13]. Speed, attentiveness and motor promptness are quite necessary to be successful in this test [18]. Slowing in reaction times of participants on Part B obviously suggests that, Part B is more difficult to perform than Part A. Use of dissimilar pair symbol systems, as numbers and letters in Part B, causes prolongation of reaction time [19].
It is well known that, length of time
Role of error analyses in Trail Making Test
In general, during scoring the scoring process of TMT, time scores are also taken into consideration, which is also emphasized in the majority of reported studies about this test [17], [19], [20], [21]. It is uncertain whether the type and number of mistakes recorded during the test, besides the time period spent to complete the test, should be taken into consideration while scoring the TMT. Two main mistakes could be mentioned for TMT: 1) Alignment error: Error in aligning numbers or letters,
Participants
The study was approved by the Local Ethics Committee of Hacettepe University and informed consent was taken from all participants. The study involves 484 healthy individuals (246 male and 238 female) distributed into seven age groups: Ages between 50 and 54, 55 and 59, 60 and 64, 65 and 69, 70 and 74, 75 and 79, 80 and over. Each group involves minimum 10 participants and educational background of participants is characterized as follows: 151 participants graduated from primary school, 161 from
Results
When results of 7 × 3 × 2 ANOVA concerning Score A, Score B, Score B − A and Score A + B values were considered, age group (F(6,442) =140.45; p < 0.001), sex (F(1,442) = 10.51; p < 0.001) and educational profile (F(2,442) = 46.89; p < 0.001) had significant influence on Score A. Mean values and standard deviations of participants over 50 years of age under various circumstances for Score A are shown in Table 2. In addition, age group and sex (F(6,442) = 2.33; p < 0.05), age group and educational profile (F(12,442) =
Validity and reliability studies
Reliability studies of the TMT test were carried out with the same pool of participants with the normative data.
Discussion
The aim of this study was to achieve a standardization of TMT for Turkish population (adults/elderly) older than 50 years of age. Norm values for eight different scores of TMT test were determined from a sample of healthy adult population older than 50 years of age. Validity and reliability analyses of the test were performed by using the same sample population. Coefficients obtained from test–retest reliability techniques, inter-rater reliability and construct validity studies were all found
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This work by supported by Hacettepe University Scientific Researches Unit, Ankara, Turkey –Project Number: 07A701002.